Contents

Search

central venous catheter

Indications: 1) hypotension requiring large fluid volume & rapid infusion 2) dehydration with no peripheral intravenous access 3) administration of pharmaceutical agents & nutrition not possible through peripheral access - vasopressors, parenteral nutrition 4) for administration of intravenous antiarrhythmic agents & vasopressors 5) measurement of central venous pressure for assessing circulating volume status [5,6] 6) management of heart failure Contraindications: 1) thrombocytopenia 2) increased prothrombin time or partial thromboplastin time - INR > 1.5 not a problem [5] 3) avoid central venous catheters if possible in patient with chronic renal failure who may eventually need hemodialysis Benefit/risk: - no difference in risk of catheter-related infection or deep vein thrombosis for femoral catheter vs subclavian catheter - number needed to harm = 73 for pneumothorax (subclavian catheter) [9] Caution: 1) Never lose sight of the guidewire 2) observe for arrhythmias is close to right atrium 3) if an attempt on one side in unsuccessful, verify the absence of pneumothorax before attempting other side Procedure: approaches* 1) subclavian vein a) from above & below the clavicle b) complications 1] pneumothorax 1-2% 2] subclavian artery puncture 1% 3] long term access 4] measurement of central venous pressure c) elective, real-time, ultrasound-guided cannulation may reduce mechanical complications & insertion time, & improve the overall success rate [12] 2) external jugular vein* a) external jugular vein runs at lateral edge of sternocleidomastoid b) eliminates risk of pneumothorax c) bleeding is easily controlled d) major problem is difficulty advancing catheter e) not well tolerated by conscious patients f) may lead to impairment of neck mobility in patients with coagulopathy g) measurement of central venous pressure 3) internal jugular vein a) access between bifurcation of sternocleidomastoid b) risk of carotid puncture 2-10% c) need to rule out pneumothorax d) contraindicated if platelets < 50,000/mm3 or if PT is > 3 sec more than control e) measurement of central venous pressure f) a small bore single lumen catheter in the internal jugular less likely to impair venous drainage from the arm than a subclavian catheter [5] 4) femoral vein a) access 1-2 cm medial to femoral artery below inguinal ligament b) no risk of pneumothorax c) bleeding easily controlled d) increased risk of infection if left in place more than 3 days e) thrombosis (10%) f) femoral artery puncture 10% g) limits flexion at hip h) location of a femoral venous line can be confirmed with injection of agitated saline during echocardiogram [7] * the most effective means of preventing complications is ultrasound-guided internal jugular catheterization, with daily assessment for continued need * 2-dimensional ultrasound helps with vein localization [3]; reduces procedure failure, vessel injury, pneumothorax [5] Complications: - 3-10% of central venous catheters are associated with major complications [15] - pneumothorax* - intravascular catheter-related infection* [10] - more common with femoral vein & internal jugular vein catheters than subclavian catheters - central venous catheters inserted under emergency condition at high risk & should be replaced within 48 hours [5] - deep vein thrombosis* (including pulmonary embolism) - more common with femoral vein & internal jugular vein catheters than subclavian catheters - superior vena cava syndrome - central venous stenosis most commonly occurs from endothelial damage from central venous catheters - use peripheral venous access if possible [5,6] - occlusion of the catheter - when a catheter permits infusion, but blood cannot be aspirated, the most likely cause is early thrombosis of the line - remove the catheter & replace it with a new one at a different site - catheters that allow neither infusion or aspiration should also be replaced - changing a line over a guide wire is not recommended - dislodgement of catheter [16] - bleeding - platelet counts < 50,000/uL prior to placement result in more bleeding [14] - arrhythmias - for short-term indications, midline catheters associated with a lower risk of bloodstream infection & occlusion compared with PICC [13] * pneumothorax can be diagnosed promptly & treated immediately intravascular catheter-related infection or deep-vein thrombosis may be more problematic [10] * also see Procedure: (above) Management: - central venous catheters inserted under emergency condition should be replaced within 48 hours [5] - hospitalized patients with central venous catheter should be assessed daily to determine if the catheter is still needed [5] - central venous catheters should be removed if fever & positive blood cultures - see intravascular catheter-related infection - patients with mild coagulopathy (INR > 1.5) do not need fresh frozen plasma or other transfusion prior to procedure [5] - chlorhexidine dressings at the catheter insertion site reduce catheter-associated infections - chlorhexidine impregnated sponges - chlorhexidine-gel dressings allow visualization of the insertion site [4] Notes: - 20% of clinicians unaware their patient has a central line [8] - teaching physicians & hospitalist more likely to be unaware of central line than interns, residents, nurse practitioners, & physician assistants (27% vs 16%) [8]

Related

cardiac catheterization central venous pressure (CVP)

Specific

central venous catheter with subcutaneous port dialysis vascular catheter midline catheter peripherally-inserted central catheter (PICC)

General

intravenous catheter (intravenous access)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 246-48
  2. Journal Watch 21(18):144, 2001 - Merrer J, De Jonghe B, Golliot F et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001 Aug 10; 286:700. PMID: 11495620
  3. Journal Watch 23(20):163, 2003 - Hind D, Calvert N, McWilliams R et al Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003 Aug 16;327(7411):361. PMID: 12919984 Free PMC Article http://bmj.bmjjournals.com/cgi/content/full/327/7411/361
  4. Timsit J-F et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012 Dec 15; 186:1272. PMID: 23043083
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  6. Hoggard J, Saad T, Schon D et al Guidelines for venous access in patients with chronic kidney disease. A Position Statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008 Mar-Apr;21(2):186-91 PMID: 18364015
  7. Horowitz R et al. The FLUSH study - Flush the Line and Ultrasound the Heart: Ultrasonographic confirmation of central femoral venous line placement. Ann Emerg Med 2014 Jan 17 PMID: 24439714
  8. Chopra V et al Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study. Ann Intern Med. 2014;161(8):562-567 PMID: 25329204 http://annals.org/article.aspx?articleid=1916822 - Taichman DB Whose Line Is It Anyway? Ann Intern Med. 2014;161(8):607-608 PMID: 25329208 http://annals.org/article.aspx?articleid=1916831
  9. The NNT: Subclavian vs. Femoral Central Line Placement. http://www.thennt.com/nnt/subclavian-vs-femoral-central-line-placement/ - Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004084. PMID: 17636746
  10. Parienti JJ et al Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373:1220-1229. September 24, 2015. PMID: 26398070 http://www.nejm.org/doi/full/10.1056/NEJMoa1500964
  11. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003 Mar 21; 348:1123 PMID: 12646670 Free full text http://www.nejm.org/doi/full/10.1056/NEJMra011883
  12. Schulman PM, Gerstein NS, Merkel MJ et al Ultrasound-Guided Cannulation of the Subclavian Vein. N Engl J Med 2018; 379:e1. July 5, 2018 PMID: 29972747 https://www.nejm.org/doi/full/10.1056/NEJMvcm1406114
  13. Swaminathan L, Flanders S, Horowitz J et al. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: A multicenter study. JAMA Intern Med 2022 Jan; 182:50-58. PMID: 34842905 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2786212
  14. van Baarle FLF et al. Platelet transfusion before CVC placement in patients with thrombocytopenia. N Engl J Med 2023 May 25; 388:1956. PMID: 37224197 https://www.nejm.org/doi/10.1056/NEJMoa2214322
  15. Teja B et al. Complication rates of central venous catheters: A systematic review and meta-analysis. JAMA Intern Med 2024 Mar 4; [e-pub]. PMID: 38436976 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2815818
  16. Corley A, Royle RH, Marsh N et al. Incidence and risk factors for central venous access device failure in hospitalized adults: A multivariable analysis of 1892 catheters. J Hosp Med 2024 Oct; 19:905 PMID: 38800854 https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13414